The impact on rural New Mexico of a family medicine residency

Interventions to improve primary healthcare in rural settings: A scoping review

BACKGROUND

Residents of rural areas have poorer health status, less healthy behaviours and higher mortality than urban dwellers, issues which are commonly addressed in primary care. Strengthening primary care may be an important tool to improve the health status of rural populations.

OBJECTIVE

Synthesize and categorize studies that examine interventions to improve rural primary care.

ELIGIBILITY CRITERIA

Experimental or observational studies published between January 1, 1996 and December 2022 that include an historical or concurrent control comparison.

SOURCES OF EVIDENCE

Pubmed, CINAHL, Cochrane Library, Embase.

CHARTING METHODS

We extracted and charted data by broad category (quality, access and efficiency), study design, country of origin, publication year, aim, health condition and type of intervention studied. We assigned multiple categories to a study where relevant.

RESULTS

372 papers met our inclusion criteria, divided among quality (82%), access (20%) and efficiency (13%) categories. A majority of papers were completed in the USA (40%), Australia (15%), China (7%) or Canada (6%). 35 (9%) papers came from countries in Africa. The most common study design was an uncontrolled before-and-after comparison (32%) and only 24% of studies used randomized designs. The number of publications each year has increased markedly over the study period from 1-2/year in 1997-99 to a peak of 49 papers in 2017.

CONCLUSIONS

Despite substantial inequity in health outcomes associated with rural living, very little attention is paid to rural primary care in the scientific literature. Very few studies of rural primary care use randomized designs.

Educational Strategies to Reduce Physician Shortages in Underserved Areas: A Systematic Review

The shortage of physicians in rural and underserved areas is an obstacle to the implementation of Universal Health Coverage (UHC). We carried out a systematic review to analyze the effectiveness of initiatives in medical education aimed to increase the supply of physicians in rural or underserved areas. We searched for studies published between 1999 and 2019 in six databases, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Interventional or observational controlled studies were defined as inclusion criteria. A total of 955 relevant unique records were selected for inclusion, which resulted in the identification of 17 articles for analysis. The admission of students from rural areas associated with a rural curriculum represented 52.95% of the interventions. Medical practice after graduation in rural or underserved areas was the most evaluated outcome, representing 12 publications (70.59%). Participants of these educational initiatives were more likely to work in rural or underserved areas or to choose family medicine, with significant differences between the groups in 82.35% of the studies. Educational strategies in undergraduate and medical residencies are effective. However, it is necessary to expand these interventions to ensure the supply of physicians in rural or urban underserved areas.

Family Medicine Residencies: How Rural Training Exposure in GME Is Associated With Subsequent Rural Practice

BACKGROUND

Rural US populations face a chronic shortage of physicians and an increasing gap in life expectancy compared to urban US populations, creating a need to understand how to increase residency graduates' desire to practice in such areas.

OBJECTIVE

This study quantifies associations between the amount of rural training during family medicine (FM) residencies and subsequent rural work.

METHODS

American Medical Association (AMA) Masterfile, AMA graduate medical education (GME) supplement, American Board of Family Medicine certification, Accreditation Council for Graduate Medical Education (ACGME), and Centers for Medicare and Medicaid Services hospital costs data were merged and analyzed. Multiple logistic regression measured associations between rural training and rural or urban practice in 2018 by all 12 162 clinically active physicians who completed a US FM residency accredited by the ACGME between 2008 and 2012. Analyses adjusted for key potential confounders (age, sex, program size, region, and medical school location and type) and clustering by resident program.

RESULTS

Most (91%, 11 011 of 12 162) residents had no rural training. A minority (14%, 1721 of 12 162) practiced in a rural location in 2018. Residents with no rural training comprised 80% (1373 of 1721) of those in rural practice in 2018. Spending more than half of residency training months in rural areas was associated with substantially increased odds of rural practice (OR 5.3-6.3). Only 4% (424 of 12 162) of residents spent more than half their training in rural locations, and only 5% (26 of 436) of FM training programs had residents training mostly in rural settings or community-based clinics.

CONCLUSIONS

There is a linear gradient between increasing levels of rural exposure in FM GME and subsequent rural work.

Medical education interventions influencing physician distribution into underserved communities: a scoping review

BACKGROUND AND OBJECTIVE

Physician maldistribution is a global problem that hinders patients' abilities to access healthcare services. Medical education presents an opportunity to influence physicians towards meeting the healthcare needs of underserved communities when establishing their practice. Understanding the impact of educational interventions designed to offset physician maldistribution is crucial to informing health human resource strategies aimed at ensuring that the disposition of the physician workforce best serves the diverse needs of all patients and communities.

METHODS

A scoping review was conducted using a six-stage framework to help map current evidence on educational interventions designed to influence physicians' decisions or intention to establish practice in underserved areas. A search strategy was developed and used to conduct database searches. Data were synthesized according to the types of interventions and the location in the medical education professional development trajectory, that influence physician intention or decision for rural and underserved practice locations.

RESULTS

There were 130 articles included in the review, categorized according to four categories: preferential admissions criteria, undergraduate training in underserved areas, postgraduate training in underserved areas, and financial incentives. A fifth category was constructed to reflect initiatives comprised of various combinations of these four interventions. Most studies demonstrated a positive impact on practice location, suggesting that selecting students from underserved or rural areas, requiring them to attend rural campuses, and/or participate in rural clerkships or rotations are influential in distributing physicians in underserved or rural locations. However, these studies may be confounded by various factors including rural origin, pre-existing interest in rural practice, and lifestyle. Articles also had various limitations including self-selection bias, and a lack of standard definition for underservedness.

CONCLUSIONS

Various educational interventions can influence physician practice location: preferential admissions criteria, rural experiences during undergraduate and postgraduate medical training, and financial incentives. Educators and policymakers should consider the social identity, preferences, and motivations of aspiring physicians as they have considerable impact on the effectiveness of education initiatives designed to influence physician distribution in underserved locations.

Recruiting and retaining general practitioners in rural practice: systematic review and meta-analysis of rural pipeline effects

OBJECTIVE

To synthesise quantitative data on the effects of rural background and experience in rural areas during medical training on the likelihood of general practitioners practising and remaining in rural areas.

STUDY DESIGN

Systematic review and meta-analysis of the effects of rural pipeline factors (rural background; rural clinical and education experience during undergraduate and postgraduate/vocational training) on likelihood of later general practice in rural areas.

DATA SOURCES

MEDLINE (Ovid), EMBASE, Informit Health Collection, and ERIC electronic database records published to September 2018; bibliographies of retrieved articles; grey literature.

DATA SYNTHESIS

Of 6709 publications identified by our search, 27 observational studies were eligible for inclusion in our systematic review; when appropriate, data were pooled in random effects models for meta-analysis. Study quality, assessed with the Newcastle-Ottawa scale, was very good or good for 24 studies, satisfactory for two, and unsatisfactory for one. Meta-analysis indicated that GPs practising in rural communities was significantly associated with having a rural background (odds ratio [OR], 2.71; 95% CI, 2.12-3.46; ten studies) and with rural clinical experience during undergraduate (OR, 1.75; 95% CI, 1.48-2.08; five studies) and postgraduate training (OR, 4.57; 95% CI, 2.80-7.46; eight studies).

CONCLUSION

GPs with rural backgrounds or rural experience during undergraduate or postgraduate medical training are more likely to practise in rural areas. The effects of multiple rural pipeline factors may be cumulative, and the duration of an experience influences the likelihood of a GP commencing and remaining in rural general practice. These findings could inform government-led initiatives to support an adequate rural GP workforce.

PROTOCOL REGISTRATION

PROSPERO, CRD42017074943 (updated 1 February 2018).

Does a socially-accountable curriculum transform health professional students into competent, work-ready graduates? A cross-sectional study of three medical schools across three countries

Background: Socially-accountable health professional education (SAHPE) is committed to achieving health equity through training health-workers to meet local health needs and serve disadvantaged populations. This research assesses the biomedical and socially-accountable competencies and work-readiness of first year graduates from socially-accountable medical schools in Australia, the United States and Sudan.Method: A self-administered survey to hospital and community health facility staff closely associated with the training and/or supervision of first year medical graduates from three SAHPE medical schools.Main outcome measure: Likert scale ratings of key competencies of SAHPE graduates (as a group) employed as first-year doctors, compared to first year doctors from other medical schools in that country (as a group).Findings: Supervisors rated medical graduates from the 3 SAHPE schools highly for socially-accountable competencies ('communication skills', 'teamwork', 'professionalism', 'work-readiness', 'commitment to practise in rural communities', 'commitment to practise with underserved ethnic and cultural populations'), as well as 'overall performance' and 'overall clinical skills'.Interpretation: These findings suggest SAHPE medical graduates are well regarded by their immediate hospital supervisors, and SAHPE can produce a medical workforce as competent as from more traditional medical schools, but with greater commitment to health equity, working with underserved populations, and addressing local health needs.

The Road to Rural Primary Care: A Narrative Review of Factors That Help Develop, Recruit, and Retain Rural Primary Care Physicians

PURPOSE

To examine the literature documenting successes in recruiting and retaining rural primary care physicians.

METHOD

The authors conducted a narrative review of literature on individual, educational, and professional characteristics and experiences that lead to recruitment and retention of rural primary care physicians. In May 2016, they searched MEDLINE, PubMed, CINAHL, ERIC, Web of Science, Google Scholar, the Grey Literature Report, and reference lists of included studies for literature published in or after 1990 in the United States, Canada, or Australia. The authors identified 83 articles meeting inclusion criteria. They synthesized results and developed a theoretical model that proposes how the findings interact and influence rural recruitment and retention.

RESULTS

The authors' proposed theoretical model suggests factors interact across multiple dimensions to facilitate the development of a rural physician identity. Rural upbringing, personal attributes, positive rural exposure, preparation for rural life and medicine, partner receptivity to rural living, financial incentives, integration into rural communities, and good work-life balance influence recruitment and retention. However, attending medical schools and/or residencies with a rural emphasis and participating in rural training may reflect, rather than produce, intention for rural practice.

CONCLUSIONS

Many factors enhance rural physician identity development and influence whether physicians enter, remain in, and thrive in rural practice. To help trainees and young physicians develop the professional identity of a rural physician, multifactorial medical training approaches aimed at encouraging long-term rural practice should focus on rural-specific clinical and nonclinical competencies while providing trainees with positive rural experiences.

Predictors of Primary Care Physician Practice Location in Underserved Urban or Rural Areas in the United States: A Systematic Literature Review

PURPOSE

The authors conducted a systematic review of the medical literature to determine the factors most strongly associated with localizing primary care physicians (PCPs) in underserved urban or rural areas of the United States.

METHOD

In November 2015, the authors searched databases (MEDLINE, ERIC, SCOPUS) and Google Scholar to identify published peer-reviewed studies that focused on PCPs and reported practice location outcomes that included U.S. underserved urban or rural areas. Studies focusing on practice intentions, nonphysicians, patient panel composition, or retention/turnover were excluded. They screened 4,130 titles and reviewed 284 full-text articles.

RESULTS

Seventy-two observational or case-control studies met inclusion criteria. These were categorized into four broad themes aligned with prior literature: 19 studies focused on physician characteristics, 13 on financial factors, 20 on medical school curricula/programs, and 20 on graduate medical education (GME) programs. Studies found significant relationships between physician race/ethnicity and language and practice in underserved areas. Multiple studies demonstrated significant associations between financial factors (e.g., debt or incentives) and underserved or rural practice, independent of preexisting trainee characteristics. There was also evidence that medical school and GME programs were effective in training PCPs who locate in underserved areas.

CONCLUSIONS

Both financial incentives and special training programs could be used to support trainees with the personal characteristics associated with practicing in underserved or rural areas. Expanding and replicating medical school curricula and programs proven to produce clinicians who practice in underserved urban or rural areas should be a strategic investment for medical education and future research.

Vision 2020 measures University of New Mexico's success by health of its state

The University of New Mexico Health Sciences Center (UNMHSC) adopted a new Vision to work with community partners to help New Mexico make more progress in health and health equity than any other state by 2020. UNMHSC recognized it would be more successful in meeting communities' health priorities if it better aligned its own educational, research, and clinical missions with their needs. National measures that compare states on the basis of health determinants and outcomes were adopted in 2013 as part of Vision 2020 target measures for gauging progress toward improved health and health care in New Mexico. The Vision focused the institution's resources on strengthening community capacity and responding to community priorities via pipeline education, workforce development programs, community-driven and community-focused research, and community-based clinical service innovations, such as telehealth and "health extension." Initiatives with the greatest impact often cut across institutional silos in colleges, departments, and programs, yielding measurable community health benefits. Community leaders also facilitated collaboration by enlisting University of New Mexico educational and clinical resources to better respond to their local priorities. Early progress in New Mexico's health outcomes measures and state health ranking is a promising sign of movement toward Vision 2020.

Exploring the workforce implications of a decade of medical school expansion: variations in medical school growth and changes in student characteristics and career plans

PURPOSE

To explore whether medical school enrollment growth may help address workforce priorities, including diversity, primary care, care for underserved populations, and academic faculty.

METHOD

The authors compared U.S. MD-granting medical schools, applicants, and matriculants immediately before expansion (1999-2001) and 10 years later (2009-2011). Using data from the American Medical Association Physician Masterfile and the Association of American Medical Colleges, they examined medical schools' past production of physicians and changes in matriculant characteristics and practice intentions.

RESULTS

Among the 124 schools existing in 1999-2001, growth varied substantially. Additionally, 11 new schools enrolled students by 2009-2011. Aggregate enrollment increased by 16.6%. Increases in applicants led to a lower likelihood of matriculation for all but those with rural backgrounds, racial/ethnic minorities, applicants >24 years old, and those with Medical College Admission Test scores > 33. The existing schools that expanded most had a history of producing the highest percentages of physicians practicing in primary care and in underserved and rural areas; those that expanded least had produced the greatest percentage of faculty. Compared with existing schools, new schools enrolled higher percentages of racial/ethnic minorities and of students with limited parental education or lower income. Matriculants' interest in primary care careers showed no decline; interest in practicing with underserved populations increased, while interest in rural practice declined.

CONCLUSIONS

Despite expansion, the characteristics of matriculating medical students changed little, except at new schools. Further expansion may benefit from targeted consideration of workforce needs.

Prioritizing health disparities in medical education to improve care

Despite yearly advances in life-saving and preventive medicine, as well as strategic approaches by governmental and social agencies and groups, significant disparities remain in health, health quality, and access to health care within the United States. The determinants of these disparities include baseline health status, race and ethnicity, culture, gender identity and expression, socioeconomic status, region or geography, sexual orientation, and age. In order to renew the commitment of the medical community to address health disparities, particularly at the medical school level, we must remind ourselves of the roles of doctors and medical schools as the gatekeepers and the value setters for medicine. Within those roles are responsibilities toward the social mission of working to eliminate health disparities. This effort will require partnerships with communities as well as with academic centers to actively develop and to implement diversity and inclusion strategies. Besides improving the diversity of trainees in the pipeline, access to health care can be improved, and awareness can be raised regarding population-based health inequalities.

Distribution of emergency departments according to annual visit volume and urban-rural status: implications for access and staffing

OBJECTIVES

ongoing efforts to improve access to emergency care and emergency department (ED) staffing would benefit from a better understanding of the distribution of EDs in the United States by size and location. This article describes the distribution of U.S. ED visit volumes according to ED urban versus rural status.

METHODS

the authors used the 2007 National Emergency Department Inventories (NEDI)-USA database to identify all nonfederal U.S. hospitals with EDs and their annual ED visit volumes. One of twelve 2003 Urban Influence Codes was applied to each ED location based on its county. These categories were collapsed into urban counties and three types of rural counties: adjacent to urban, large nonadjacent, and small nonadjacent. The number of emergency physicians (EPs) needed to staff the higher-volume rural EDs was estimated.

RESULTS

of the 4,874 U.S. EDs in 2007, 58% were in urban counties and 42% in rural counties. Among the 2,038 rural EDs, 56% were adjacent to urban, 15% were large nonadjacent, and 29% were small nonadjacent. Of the 1,503 lower-volume (< 10,000 visit) EDs, 21% were in urban counties. Of the 3,371 higher-volume (≥ 10,000 visit) EDs, 25% were in rural counties. Of the 857 higher-volume rural EDs, 66% were adjacent to urban, 22% were large nonadjacent, and 12% were small nonadjacent. The authors estimate that approximately 5,600 EPs are needed to staff these higher-volume rural EDs.

CONCLUSIONS

there are many lower-volume EDs in urban areas and higher-volume EDs in rural areas. Most higher-volume rural EDs are in rural areas adjacent to urban counties. These data challenge popular assumptions regarding ED visit volumes, locations, and staffing needs.

Recruiting and retaining physicians in very rural areas

CONTEXT

Recruiting and retaining physicians is a challenge in rural areas. Growing up in a rural area and completing medical training in a rural area have been shown to predict decisions to practice in rural areas. Little is known, though, about factors that contribute to physicians' decisions to locate in very sparsely populated areas.

PURPOSE

In this study, we investigated whether variables associated with rural background and training predicted physicians' decisions to practice in very rural areas. We also examined reasons given for plans to leave the study state.

METHODS

Physicians in the State of Wyoming (N = 693) completed a questionnaire assessing their background, current practice, and future practice plans.

FINDINGS

Being raised in a rural area and training in nearby states predicted practicing in very rural areas. High malpractice insurance rates predicted planning to move one's practice out of state rather than within state.

CONCLUSIONS

Rural backgrounds and training independently predict practice location decisions, but high malpractice rates are the most crucial factor in future plans to leave the state.

Evaluated strategies to increase attraction and retention of health workers in remote and rural areas

The lack of health workers in remote and rural areas is a worldwide concern. Many countries have proposed and implemented interventions to address this issue, but very little is known about the effectiveness of such interventions and their sustainability in the long run. This paper provides an analysis of the effectiveness of interventions to attract and retain health workers in remote and rural areas from an impact evaluation perspective. It reports on a literature review of studies that have conducted evaluations of such interventions. It presents a synthesis of the indicators and methods used to measure the effects of rural retention interventions against several policy dimensions such as: attractiveness of rural or remote areas, deployment/recruitment, retention, and health workforce and health systems performance. It also discusses the quality of the current evidence on evaluation studies and emphasizes the need for more thorough evaluations to support policy-makers in developing, implementing and evaluating effective interventions to increase availability of health workers in underserved areas and ultimately contribute to reaching the United Nations' Millennium Development Goals.

Factors that influence physicians to practice in rural locations: a review and commentary

Rural populations remain underserved by physicians, despite various efforts by medical schools and other institutions/organizations to correct this disparity. We examined the literature on factors that influence rural practice location decisions by physicians to determine what opportunities exist along the entire educational pipeline to entice physicians to, and retain them in, rural areas. Results reported in the literature favor a multidisciplinary or multi-faceted approach that results in more residents and physicians locating their practices in rural areas. The need to define proven strategies is not the pressing issue; rather, the needs are to define the commitments necessary to implement proven strategies, as well as the will to make physician distribution a priority issue in medical education.

The physician pipeline to rural and underserved areas in Pennsylvania

CONTEXT

An implicit objective of a state's investments in medical education is to promote in-state practice of state educated physicians.

PURPOSE

To present a tool for evaluating this objective by analyzing the "pipeline" from medical education to patient care, primary care, rural areas, and underserved areas in Pennsylvania.

METHODS

AMA Masterfile data (2004) including all physicians with a Pennsylvania address or who received medical education in Pennsylvania were analyzed. These data were combined with local physician supply data.

RESULTS

About 36% of Pennsylvania medical school graduates provide patient care in the Commonwealth, 16% primary care, 7% rural care, 4% rural primary care, and 0.5% primary care in a rural underserved area. Fifty-four percent of physicians who received both undergraduate and graduate medical education in-state are retained.

CONCLUSIONS

These retention rates have developed within the context of a middle-of-the-road educational pipeline policy. If Pennsylvania policy makers consider that further pipeline development is advisable, there is room to amend current policy to that end. Conditions are favorable for other states to consider similar policy amendments.

Addressing physician shortages in New Mexico through a combined BA/MD program

The University of New Mexico School of Medicine and College of Arts and Sciences developed its combined BA/MD degree program, which will increase the medical school class from 75 students to 100 in the fall of 2010, to address the critical issue of physician shortages in underserved New Mexico. The program, which began operation at the undergraduate (i.e., college) level in 2006, expands opportunities in medical education for New Mexico students, especially those from rural and underserved minority communities, and prepares them to practice in underserved areas of New Mexico. In the BA/MD program, students will earn a bachelor of arts, a medical degree, and a proposed certificate in public health. A challenging liberal arts curriculum introduces the principles of public health. Students have unique rural medicine and public health preceptorship opportunities that begin in the undergraduate years and continue throughout medical school. Students work with a community physician mentor in summer service-learning projects during the undergraduate years, then they return for required rural medicine rotations in the first, third, and fourth years of medical school. Simultaneously, the classroom curriculum for these rural medicine experiences emphasizes the public health perspective. High priority has been placed on supporting students with academic advising and counseling, tutoring, supplemental instruction, on-campus housing, and scholarships. The program has received strong support from communities, the New Mexico state legislature, the New Mexico Medical Society, and the faculties of arts and sciences and the school of medicine. Early results on the undergraduate level demonstrate strong interest from applicants, retention of participants, and enthusiasm of students and faculty alike.

The TennCare graduate medical education plan: ten years later

BACKGROUND

In 1994, Tennessee converted its Medicaid program to a managed care system--TennCare. Graduate medical education (GME) funding by TennCare was linked to several workforce goals that included increasing the number of residents training in primary care and increasing the number of primary care physicians practicing in underserved areas of Tennessee.

OBJECTIVES

To determine the effects of the TennCare GME plan on GME and the physician workforce of Tennessee.

DESIGN, SETTING, AND PARTICIPANTS

Bureau of TennCare GME data from 1996-2004 and American Medical Association Physician Masterfile data through 2003.

MEASUREMENTS

Changes in filled residency positions and number of stipend supplements awarded after implementation of the TennCare GME plan. Changes in physician workforce characteristics between a 5-year period before and after implementation of TennCare.

RESULTS

Filled primary care residency positions increased from 839 (45.2%) in 1996 to 906 (47.9%) in 2000, but declined to 862 (43.5%) by 2004. Eleven of 133 available primary care stipend supplements were awarded through 2004. The percentage of physicians remaining in Tennessee after completion of residency decreased from 46.2% before TennCare to 42.4% (P = .087) after implementation of TennCare. U.S. medical graduates remaining in state declined by 5.8% (P = .019).

CONCLUSIONS

The major goals of the TennCare GME plan have not been achieved. Overall, physician retention has decreased and the number of U.S. medical graduates remaining in state has declined. State policymakers should consider other methods to increase the number of residents training in primary care and ultimately practicing in underserved areas of Tennessee.

Viewpoint: Developing a physician workforce for America's disadvantaged

Eliminating health disparities will be difficult as long as many rural and disadvantaged inner-city communities remain medically underserved. The authors argue that the current debate on physician workforce policy has not adequately emphasized medical schools' social mission to educate physicians who will improve health care access and equity; fulfilling that mission means training students who will deliver primary care to underserved people. But fewer medical students are entering primary care specialties and practicing in underserved areas, and students who have the characteristics that make them likely to select such careers are increasingly uncommon among medical school matriculants. Unless there is a dramatic change, the imbalance will only become worse. The authors argue that the epidemiology of medical student career choice is sufficiently understood to permit schools to accept applicants with those characteristics, both demographic and individual, that are known to increase the probability of students caring for populations in need after graduation. Programs that have selected students on the basis of those predictors have been successful in increasing the distribution of doctors to primary care specialties and underserved areas, but these have not been of sufficient scope. The authors present a proposal for prioritizing medical school admissions to favor applicants who, rather than delivering just high grades, will contribute to improving America's health care outcomes.

The Health Commons and care of New Mexico's uninsured

PURPOSE

A seamless system of social, behavioral, and medical services for the uninsured was created to address the social determinants of disease, reduce health disparities, and foster local economic development in 2 inner-city neighborhoods and 2 rural counties in New Mexico.

METHODS

Our family medicine department helped urban and rural communities that had large uninsured, minority populations create Health Commons models. These models of care are characterized by health planning shared by community stakeholders; 1-stop shopping for medical, behavioral, and social services; employment of community health workers bridging the clinic and the community; and job creation.

RESULTS

Outcomes of the Health Commons included creation of a Web-based assignment of uninsured emergency department patients to primary care homes, reducing return visits by 31%; creation of a Web-based interface allowing partner organizations with incompatible information systems to share medical information; and creation of a statewide telephone Health Advice Line offering rural and urban uninsured individuals access to health and social service information and referrals 24 hours a day, 7 days a week. The Health Commons created jobs and has been sustained by attracting local investment and external public and private funding for its products. Our department's role in developing the Health Commons helped the academic health center (AHC) form mutually beneficial community partnerships with surrounding and distant urban and rural communities.

CONCLUSIONS

Broad stakeholder participation built trust and investment in the Health Commons, expanding services for the uninsured. This participation also fostered marketable innovations applicable to all Health Commons' sites. Family medicine can promote the Health Commons as a venue for linking complementary strengths of the AHC and the community, while addressing the unique needs of each. Overall, our experience suggests that family medicine can play a leadership role in building collaborative approaches to seemingly intractable health problems among the uninsured, benefiting not only the community, but also the AHC.

Beyond the horizon: the role of academic health centers in improving the health of rural communities

Academic health centers (AHCs) face increasing pressures from federal, state, and community stakeholders to fulfill their social missions to the communities they serve. Yet, in the 21st century, rural communities in the United States face an array of health care problems, including a shortage of physicians, health problems that disproportionately affect rural populations, a need to improve quality of care, and health disparities related to disproportionate levels of poverty and shifting demographics. AHCs have a key role to play in addressing these issues. AHCs can increase physician supply by targeting their admissions policies and educational programs. Specific health concerns of rural populations can be further addressed through increased use of telemedicine consultations. By partnering with providers in rural areas and through the use of innovative technologies, AHCs can help rural providers increase the quality of care. Partnerships with rural communities provide opportunities for participatory research to address health disparities. In addition, collaboration between AHCs, regional planning agencies, and rural communities can lead to mutually beneficial outcomes. At a time when many AHCs are operating in an environment with dwindling resources, it is even more critical for AHCs to build creative partnerships to help meet the needs of their regional communities.

The University of New Mexico Visiting Physicians Program: Helping Older New Mexicans Stay at Home

New Mexico is a rural state with unique barriers to health service delivery to homebound elderly. The University of New Mexico’s Visiting Physicians Program allows these patients to stay in their homes by bringing physicians to them. The physicians use community agencies to provide nursing, lab, X-ray, and physical therapy services. The University of New Mexico has also integrated home visits into the medical students, residents and geriatric fellows’ educational programs. By involving medical students, residents and fellows in home care, future physicians who practice in New Mexico will incorporate this valuable service into care for the homebound elderly in their practice communities.